Provider Demographics
NPI:1174664890
Name:CLARK, JOHN CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1325 BAMBURY CT
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-1339
Mailing Address - Country:US
Mailing Address - Phone:530-246-4971
Mailing Address - Fax:530-241-6847
Practice Address - Street 1:1325 BAMBURY CT
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1339
Practice Address - Country:US
Practice Address - Phone:530-246-4971
Practice Address - Fax:530-241-6847
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA240262085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23792Medicare UPIN